A person is subject to administrative actions or sanctions
if the person:
(1) is excluded or terminated for cause on or after
January 1, 2011, under Title XVIII of the Social Security Act or under
the Medicaid program or CHIP of any other state;
(2) commits an act for which sanctions, damages, penalties,
or liability could be or are assessed by the OIG;
(3) fails to repay overpayments or other assessments
after receiving written notice of the overpayment or of delinquency
by the OIG or any HHS program or HHS agency;
(4) fails to repay overpayments within 60 calendar
days of self-identifying or discovering an overpayment that was made
to the person by the Medicaid, CHIP or other HHS program;
(5) fails to comply, when required for participation
in Medicaid or other HHS program or award, with financial record and
supporting document retention requirements designed to ensure that
a person's claims or costs may be reviewed objectively for accuracy
and validity. Such requirements include compliance with:
(A) United States Office of Management and Budget (OMB)
circulars;
(B) generally accepted accounting principles (GAGAS);
(C) state or federal law; or
(D) contractual requirements;
(6) fails to comply, when required for participation
in Medicaid or other HHS program or award, with standards or requirements
related to allowable and valid expenses and costs, including requirements
related to cost allocation methodologies and the correct application
of cost allocation methodologies. Such standards include compliance
with:
(A) OMB circulars;
(B) GAGAS;
(C) state or federal law; or
(D) contractual requirements;
(7) fails to establish an effective compliance program
for detecting criminal, civil, and administrative violations, that
promotes quality of care, contains appropriate protection for whistleblowers,
and contains the core elements identified in the federal sentencing
guidelines for corporations or established by the United States Secretary
of Health and Human Services;
(8) fails to ensure that items or services furnished
personally by, at the direction of, or on the prescription or order
of an excluded person are not billed to the Titles V, XIX, XX, or
CHIP programs after the effective date of the person's exclusion,
whether the exclusion was imposed directly or through an MCO, or through
an individual or a group billing number;
(9) fails to comply with Medicaid or other HHS program
policy, a published medical assistance or other HHS program bulletin,
a policy notification letter, a provider policy or procedure manual,
a contract, a statute, a rule, a regulation, or an interpretation
previously published or sent to the provider by an operating agency
or the Commission, including statutes or standards governing occupations;
(10) fails to comply with the terms of Medicaid or
other HHS program contract, provider enrollment application, provider
agreement or amendment, assignment agreement, the provider certification
on Medicaid or other HHS program claim form or rules or regulations
published by the Commission or the medical assistance program or other
HHS operating agency;
(11) enrolls as a provider as a corporation and loses
or forfeits its corporate charter, and fails to obtain reinstatement
retroactive to the time of the original loss or forfeiture;
(12) was found liable in a court judgment, assumed
liability for repaying an overpayment in a settlement agreement or
was convicted of a violation relating to performance of a provider
agreement or program violation of Medicare, Texas Medicaid, other
HHS program, or any other state's Medicaid program;
(13) fails to comply with any provision of the Texas
Human Resources Code Chapter 32 or 36, the Texas Government Code,
the Texas Health and Safety Code, or any rule or regulation issued
under those codes;
(14) fails to abide by applicable federal and state
law regarding persons with disabilities or civil rights;
(15) fails to correct deficiencies in provider operations,
medical care, billing, records management, or reporting after receiving
written notice of them from an operating agency, the Commission, or
their authorized agents;
(16) defaults on repayments of scholarship obligations
or items relating to health profession education made or secured,
in whole or in part, by the United States Department of Health and
Human Services or the state when all reasonable steps have been taken
to secure repayment;
(17) fails to notify and reimburse the relevant operating
agency or the Commission or their agents for services paid by Medicaid
or other HHS program if the provider also receives reimbursement from
a liable third party;
(18) requests from a third party liable for payment
of the services or items provided to a recipient under Medicaid or
other HHS program, any payment other than as authorized by 42 C.F.R. §447.20;
(19) unless otherwise allowed by law, solicits recipients
or causes recipients to be solicited, through offers of transportation
or otherwise, for the purpose of delivering to those recipients health
care items or services or solicits for treatment or treats a child
who was not accompanied by an authorized adult or who was accompanied
by the provider or its affiliate to treatment;
(20) fails to include within any subcontracts for services
or items to be delivered within Medicaid all information that is required
by 42 C.F.R. §434.10(b);
(21) fails, as a hospital, to comply substantially
with a corrective action required under 42 U.S.C. §1395ww(f)(2)(B);
(22) commits an act described as grounds for exclusion
under 42 U.S.C. §1320a-7(a) (civil monetary penalties for false
claims) or 42 U.S.C. §1320a-7(b) (criminal liability for health
care violations);
(23) could be excluded for any reason for which the
Secretary of the United States Department of Health and Human Services
or its agent could exclude such person under 42 U.S.C. §1320a-7(a)
(mandatory exclusion), 42 U.S.C. §1320a-7(b) (permissive exclusion),
or 42 C.F.R. Part 1001 or 1003;
(24) prevents, obstructs, impedes, or attempts to impede
the OIG or any other federal or state agency, division, agent, or
consultant from conducting any duties that are necessary to the performance
of their official functions;
(25) fails to screen all employees and contractors
for exclusions from the Medicaid or other HHS program on a monthly
basis and to confirm that no employees or contractors are excluded
individuals or entities;
(26) fails to document that the provider and its employees
and contractors are not excluded;
(27) fails to immediately inform the OIG after identification
of an excluded employee;
(28) fails to immediately inform the OIG when the provider
takes any action against an employee or contractor, including suspension
actions, settlement agreements, and situations where an individual
or entity voluntarily withdraws from the program to avoid a formal
sanction;
(29) fails to refund Medicaid for funds spent, if any,
for an excluded person's salary, expenses, or fringe benefits paid
during the period of exclusion if those funds were reflected or calculated
into a cost report or any other document used by the state to determine
an individual payment rate, a statewide payment rate, or a fee;
(30) commits any act or omission described in:
(A) 42 C.F.R. §1001.801 (failure of health maintenance
organizations and Competitive Medical Plans to furnish medically necessary
items or services);
(B) 42 C.F.R. §1001.901 (false or improper claims);
(C) 42 C.F.R. §1001.951 (fraud and kickbacks and
other prohibited activities);
(D) 42 C.F.R. §1001.1001 (exclusion of entities
owned or controlled by a sanctioned person);
(E) 42 C.F.R. §1001.1051 (exclusion of individuals
with ownership or control interest in sanctioned entities);
(F) 42 C.F.R. §1001.1101 (failure to disclose
certain information);
(G) 42 C.F.R. §1001.1501 (default of health education
loan or scholarship obligations);
(H) 42 C.F.R. §1001.1601 (violations of the limitations
on physician charges); or
(I) 42 C.F.R. §1001.1701 (billing for services
of assistant at surgery during cataract operations); or
(31) commits or conspires to commit a violation of §32.039(b)
of the Texas Human Resources Code.
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